Supervisory Health & Safety Survey

Supervisory Health and Safety Survey

This Supervisory Health and Safety Survey was developed by the Bureau of State Risk Management to help state agencies and other organizations to assess and quantify the level of supervisory health and safety training within their organization. The survey asks supervisors to indicate the types of health and safety training they have received, the types of training they have given to their employees, and what types of training would benefit them and their organization the most. The survey also asks supervisors if they are aware if their organization has developed a written program, policy or procedure pertaining to a specific topic or activity. The results of this survey can help determine your organization's compliance status with key Department of Commerce/OSHA standards and perhaps certain internal activities such as conducting safety inspections and job hazard assessments. The survey can also help you determine your immediate and long- term training needs for supervisors and employees. Please note that this survey can be adapted to fit your specific organization and areas of concern. The individual sending out the survey should indicate his/her name, the date the completed survey should be returned, and his/her mailing address at the bottom of the survey. Supervisory Health and Safety Survey

Please take a few minutes to complete the survey below. As a Supervisor, you play a critical role in accident prevention. This survey is designed to evaluate your current level of health and safety training and the need for additional training. Please circle the appropriate response. If you believe that a particular topic or activity does not apply to your agency, circle 'n/a'. Thank you for your time.

General Information: Name (optional): Department: Number of Employees Supervised: Years in Supervision:

Does this Does your Have you Have you Does your From 1 (low) to 5 TOPIC topic agency have a ever been ever trained agency (high), how much apply to written trained on your need benefit would your program or this topic? employees on training on training on this agency? policy this topic? this topic? topic provide addressing you? this topic?

General Safety Rules Y N Y N n/a Y N n/a Y N n/a Y N n/a 1 2 3 4 5 Compressed Gas Cylinders Y N Y N n/a Y N n/a Y N n/a Y N n/a 1 2 3 4 5 Hazard Communication Y N Y N n/a Y N n/a Y N n/a Y N n/a 1 2 3 4 5 Electrical Safety Y N Y N n/a Y N n/a Y N n/a Y N n/a 1 2 3 4 5 Emergency Response Planning Y N Y N n/a Y N n/a Y N n/a Y N n/a 1 2 3 4 5 Hearing Conservation Y N Y N n/a Y N n/a Y N n/a Y N n/a 1 2 3 4 5 Powered Industrial Trucks Y N Y N n/a Y N n/a Y N n/a Y N n/a 1 2 3 4 5 Lockout/Tagout Y N Y N n/a Y N n/a Y N n/a Y N n/a 1 2 3 4 5 Respiratory Protection Y N Y N n/a Y N n/a Y N n/a Y N n/a 1 2 3 4 5 Confined Space Entry Y N Y N n/a Y N n/a Y N n/a Y N n/a 1 2 3 4 5 Fire Extinguishers Y N Y N n/a Y N n/a Y N n/a Y N n/a 1 2 3 4 5 Fall Protection Y N Y N n/a Y N n/a Y N n/a Y N n/a 1 2 3 4 5 Bloodborne Pathogens Y N Y N n/a Y N n/a Y N n/a Y N n/a 1 2 3 4 5 Personal Protective Equipment Y N Y N n/a Y N n/a Y N n/a Y N n/a 1 2 3 4 5 Workplace Violence Y N Y N n/a Y N n/a Y N n/a Y N n/a 1 2 3 4 5 Does this Does your Have you Have you Does your From 1 (low) to 5 ACTIVITY activity agency have ever been ever trained agency (high), how much apply to written trained on your need benefit would your procedures this employees on training on training on this agency? for this activity? this activity? this activity provide activity? activity? you?

Accident reporting/investigations Y N Y N n/a Y N n/a Y N n/a Y N n/a 1 2 3 4 5 Safety meetings with employees Y N Y N n/a Y N n/a Y N n/a Y N n/a 1 2 3 4 5 Department safety inspections Y N Y N n/a Y N n/a Y N n/a Y N n/a 1 2 3 4 5 Safety orientation/training of new Y N Y N n/a Y N n/a Y N n/a Y N n/a 1 2 3 4 5 and/or current employees Worker's Compensation claims Y N Y N n/a Y N n/a Y N n/a Y N n/a 1 2 3 4 5 Medical/First Aid treatment Y N Y N n/a Y N n/a Y N n/a Y N n/a 1 2 3 4 5 Return to Work/Restrictive Duty Y N Y N n/a Y N n/a Y N n/a Y N n/a 1 2 3 4 5 Job Hazard Assessments Y N Y N n/a Y N n/a Y N n/a Y N n/a 1 2 3 4 5 Planned observations of employees Y N Y N n/a Y N n/a Y N n/a Y N n/a 1 2 3 4 5 Enforcement of safe work practices Y N Y N n/a Y N n/a Y N n/a Y N n/a 1 2 3 4 5

Return this survey to: ______By: ______

Mailing Address: ______